304313614-6-18-2019-06-CC-GMAI-BD9RLZ-20190618130755

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304313614
Report Date: 06/18/2019
Date Signed: 06/18/2019 01:08:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	SIMPSON, MICHELLE		FACILITY NUMBER:	304313614
ADMINISTRATOR:	SIMPSON, MICHELLE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 650-8174
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92805
CAPACITY:	14	CENSUS: 0	DATE:	06/18/2019
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Michelle Simpson - Applicant		TIME COMPLETED:	01:15 PM

NARRATIVE

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Licensing Program Analysts (LPAs), Gigi Mai and Andrea Taylor conducted an announced Pre-Licensing inspection of the home. This is an application for a relocation from facility #304312913. The LPAs toured the home with the applicant, Michelle Simpson. The applicant has requested a license for a large family child care home with operating hours of Monday through Friday 4:00 AM to 6:30 PM. A review of adults' records on today's date indicates that all adults live in the home or individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The home was clean, orderly, and was at a comfortable temperature. The facility is single story family home with 4 bedrooms, 2 bathrooms, living room, dining room, kitchen, detached garage, front yard and fenced backyard. There is a covered outdoor play area that is an open space between the back door and leads to the detached garage. The two ends of the play area are open, one to the back yard and one to the other side of the house. Applicant understand that the outdoor play area cannot be the main area for daycare. Off limits area are: three bedrooms, master bathroom and garage; off limits areas were inspected today. The applicant acknowledged the children may never enter the off-limit areas.

Cleaning solutions/chemicals, utensils, and sharp knives are all inaccessible. The kitchen cabinets and stove are equipped by the plastic latches/covers. Applicant stated poisons/hazardous items are key locked in the outdoor storage area. Applicant understands that cleaning solutions/chemicals must be made inaccessible to children at all times and poisonous items must be key/combo locked at all times.

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SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gigi Mai	TELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SIMPSON, MICHELLE	FACILITY NUMBER: 304313614
	VISIT DATE: 06/18/2019

NARRATIVE

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If the facility receives a Type A violation, the licensee shall post and provide copies of the report to parents/guardians of the children in care at the facility by the next business day and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. Additionally, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days and provide a copy to current and enrolling parents. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file.

This facility will need to correct the following prior to issue of a license and send proof of the corrections to the CCLD office within 30-days.

1) Door knob covers for all off-limit areas
2) Wall heater needs to be inaccessible
3) Removal of all 3 broken play yards
4) Removal of 2 baby rockers
5) Large crack in concrete floor in backyard needs to be repaired

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SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gigi Mai	TELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2019

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SIMPSON, MICHELLE	FACILITY NUMBER: 304313614
	VISIT DATE: 06/18/2019

NARRATIVE

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LPAs reviewed Unusual Incident Report form and advised the applicant to contact Licensing Officer of the Day within 24 hours by phone or fax and complete the Unusual Incident Report (LIC 624B) within seven days. LPAs reviewed with the applicant of Title 22 regulations, requirements of disaster drills (documented every 6 months), posting requirements, children’s records, facility/staff records, mandated child abuse and injury/death reporting. LPAs explained to the applicant of children's rights, including no intimidation, humiliation, and no corporal punishment. The facility license number must be on all advertisements, publications or announcements with the intent to attract clients.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the licensing office within 30 days of providing IMS. The plan should describe the facility’s policies and procedures that ensure the proper safeguards are in place. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

A Child Care Provider’s Guide to Safe Sleep packet, Safety Seat, Never Ever Shake a Baby information, Safe Sleep Regulation, and Effects of Lead Exposure were discussed and provided to the applicant. The applicant was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov

The applicant was provided a copy of their appeal rights (LIC9058 12/15) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the licensing office within 15 business days. First level appeal is to Regional manager, address is above on the report. The applicant was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov.

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SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gigi Mai	TELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2019

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SIMPSON, MICHELLE	FACILITY NUMBER: 304313614
	VISIT DATE: 06/18/2019

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There are age appropriate toys and napping equipment on the premises for the potential ages served. There are no bodies of water on the premises. There is a fountain in the front yard but it is used as a garden bed with flowers. The applicant stated that there are no firearms on the premises. LPAs advised anytime when firearms are present, they must be locked and stored separately from the ammunition. Fire extinguisher (2A:10BC) observed to be fully charged, a smoke detector and carbon monoxide detector were present and were functioning during today's inspection. Applicant understands the home is to be free from smoking at all times and children are never to be left in a vehicle or unsupervised.

LPAs reviewed 16 hours Preventative Health Practice/Nutrition, Current Pediatric CPR/First Aid certification (exp. 04/2021), and they are EMSA approved. Current immunization information for pertussis, measles, and influenza were verified by LPA. The LPAs advised of Affidavit Regarding Liability Insurance (LIC 282) if did not purchase liability insurance and to maintain the form in all children's files.

The LPAs advised the applicant to contact licensing for any changes of off limit areas, operation hours or change in phone number, change in persons living in the home or children turning 18. The applicant has a landline that is used for child care. In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR training, Immunization's as required by SB 792 (pertussis, measles, and influenza), mandated reporter training and a valid criminal record clearance associated to the facility license.

The following were discussed: Individuals who are 18 years of age or older living or working in the home must be fingerprinted cleared prior to being present in the facility. If adult is fingerprinted cleared and associated to another facility, licensee must complete a Criminal Record Clearances or Exemption Transfer Request form (LIC 9182 or LIC 9188) with copy of ID and Criminal Record Statement (LIC 508) and fax to (714)703-2831 prior to hiring adult.

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SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gigi Mai	TELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2019

LIC809 (FAS) - (06/04)

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